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Published on: January 17, 2014
Clinical features and inflammatory markers in pediatric pneumonia: a prospective study
Are Stuwitz Berg1,2, Christopher Stephen Inchley3, Hans Olav Fjaerli3
1Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Postal Box 1000, 1478, Lørenskog, Norway. arebe@medisin.uio.no.
Insights
In children, high C-reactive protein (CRP) and low oxygen saturation (SpO2) can help identify pneumonia on chest X-rays and bacterial causes. However, low sensitivity limits their clinical use.
Area of Science:
- Pediatrics
- Infectious Diseases
- Diagnostic Imaging
Background:
- Pneumonia diagnosis is often clinical, with limited ability to distinguish etiology using clinical features or inflammatory markers.
- The emergence of the pneumococcal conjugate vaccine has altered the common causes of pneumonia in children.
- Differentiating between bacterial and viral pneumonia is crucial for appropriate treatment, especially in the post-vaccination era.
Purpose of the Study:
- To evaluate the diagnostic accuracy of clinical signs and inflammatory markers in predicting pneumonia on chest radiography.
- To assess the ability of these markers to differentiate the etiology of radiographically confirmed pneumonia in children.
- To investigate the utility of C-reactive protein (CRP) and white blood cell (WBC) counts in diagnosing pneumonia and its causes.
Main Methods:
- Prospective, observational study of 394 previously healthy children under 18 years with suspected pneumonia.
- Analysis of clinical features, C-reactive protein (CRP) levels, white blood cell (WBC) counts, and oxygen saturation (SpO2).
- Multivariate logistic regression used to identify associations with positive chest radiography and bacterial etiology in proven pneumonia.
Main Results:
- Positive chest radiography in suspected pneumonia was linked to higher CRP, older age, and lower SpO2 (≤92%).
- Bacterial pneumonia was differentiated from viral/atypical pneumonia by higher CRP and higher SpO2 (>92%).
- High CRP and WBC counts showed high specificity (>85%) but low sensitivity (<46%) for radiographic and bacterial pneumonia.
Conclusions:
- CRP, WBC count, and hypoxemia can aid in identifying radiographic pneumonia and bacterial etiology, but their low sensitivity restricts clinical utility.
- In the post-pneumococcal vaccination era, a 'watch-and-wait' approach for antibiotics may be suitable for pneumonia cases with low CRP and WBC counts.
- While useful for ruling in, these markers are less effective for ruling out pneumonia or bacterial infection due to low sensitivity.
Abstract:
In this prospective, observational study on previously healthy children <18 years, we aimed to study the diagnostic ability of clinical features and inflammatory markers to (i) predict pathologic chest radiography in suspected pneumonia and (ii) differentiate etiology in radiological proven pneumonia. In 394 cases of suspected pneumonia, 265 (67%) had radiographs consistent with pneumonia; 34/265 had proof of bacterial etiology. Of the cases, 86.5% had received pneumococcal conjugate vaccine. In suspected pneumonia, positive chest radiography was significantly associated with increasing C-reactive protein (CRP) values, higher age, and SpO2 ≤92% in multivariate logistic regression, OR 1.06 (95% CI 1.03 to 1.09), OR 1.09 (95% CI 1.00 to1.18), and OR 2.71 (95% CI 1.42 to 5.18), respectively. In proven pneumonia, bacterial pneumonia was significantly differentiated from viral/atypical pneumonia by increasing CRP values and SpO2 >92% in multivariate logistic regression, OR 1.09 (95% CI 1.05 to 1.14) and OR 0.23 (95% CI 0.06 to 0.82), respectively. Combining high CRP values (>80 mg/L) and elevated white blood cell (WBC) count provided specificity >85%, positive likelihood ratios >3, but sensitivity <46% for both radiographic proven and bacterial pneumonia.
Conclusion:
With relatively high specificity and likelihood ratio CRP, WBC count and hypoxemia may be beneficial in ruling in a positive chest radiograph in suspected pneumonia and bacterial etiology in proven pneumonia, but with low sensitivity, the clinical utility is limited. What is Known: • Pneumonia is recommended to be a clinical diagnosis, and neither clinical features nor inflammatory markers can reliably distinguish etiology. • The etiology of pneumonia has changed after routine pneumococcal conjugate vaccine. What is New: • High CRP and WBC counts were associated with infiltrates in children with suspected pneumonia and with bacterial infection in proven pneumonia. • In the post-pneumococcal vaccination era, viral etiology is expected, and in cases of pneumonia with low CRP and WBC counts, a watch-and-wait strategy for antibiotic treatment may be applied.
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